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The ‘three Ps’ of cancer survivorship carePatricia A Ganz
What is the definition of ‘cancer survivor’ andwhat is ‘survivorship care’?With the growing numbers of individuals surviving longterm and disease free after a cancer diagnosis, a groupof individuals in the US came together in 1986 to estab-lish the National Coalition for Cancer Survivorship(NCCS; http://www.canceradvocacy.org), and definedcancer survivors as individuals with cancer from thetime of diagnosis and for the balance of life, andincluded in its definition family, friends and caregivers.This broad and all-inclusive definition reminds us thatpotentially anyone with a diagnosis of cancer can be along-term survivor and that we must design therapies atthe outset to maximize cure as well as minimize long-term side effects and other more serious effects of can-cer treatments. In practical terms, however, we tend tofocus on the post-treatment phase of the cancer experi-ence, and that is where survivorship care really getsstarted (Figure 1).
Why is survivorship care something that needsdealing with?The reason for the focus on survivorship care is that ithas been largely neglected. The medical care system pri-marily focuses on curing the cancer and not on how tomanage the after effects. Patients are often left wonder-ing about how often they need to be seen after treat-ment ends and what follow-up tests need to beperformed. In addition, they are often troubled by per-sistent symptoms and side effects of treatment that themedical care system seldom attends to, and these pro-blems may cause ongoing suffering and burden. Finally,cancer survivors often neglect other aspects of theirhealth and may remain at risk for second cancers andother serious chronic diseases (for example, heart dis-ease, diabetes).
What are the ‘three Ps’?As I began lecturing about survivorship care I wanted tocome up with something catchy to help people remem-ber the important components of post-treatment survi-vorship care. Conceptually, the care delivery falls intothree major domains: Palliation of ongoing symptoms;Prevention of late effects of cancer treatment or secondcancers; and Health Promotion to maximize futurewellness. For example, the cancer may be gone, butpatients still can suffer from pain, fatigue or depression,for which palliative care approaches become central.Prevention of the late effects means monitoring and pre-venting common late effects such as osteoporosis,screening for second cancers (for example, skin exams,breast cancer after chest radiation). Health promotion isoften overlooked because everyone is concentrating onmonitoring for cancer recurrence, when in fact manyadults are at risk for and will die from cardiovasculardisease, stroke or diabetes complications. Making surethat all three Ps are addressed is an important aspect ofsurvivorship care.
What led to the development of these concepts?I was a member of the Institute of Medicine (IOM)committee that prepared a report on the challengesassociated with addressing the needs of post-treatmentcancer survivors (see Hewitt et al, 2006). This reportdocumented the growing number of cancer survivorsliving after treatment ends and how they were ‘lost intransition’ with little guidance or coordination in theirhealth care, and their unmet health care needs. Thereport clearly states that there is a need to acknowledgethis phase of the cancer care trajectory, to do moreresearch to better understand how care should be pro-vided, and to focus on improvement in the coordinationand quality of care through use of a treatment summaryand survivorship care plan.
What is the IOM?The IOM is part of the US National Academy ofSciences and is responsible for providing independentunbiased advice on issues related to biomedical science,
Correspondence: [email protected] Schools of Medicine and Public Health, Division of Cancer Prevention& Control Research, Jonsson Comprehensive Cancer Center, Los Angeles, CA,USA
Ganz BMC Medicine 2011, 9:14http://www.biomedcentral.com/1741-7015/9/14
© 2011 Ganz; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.
medicine, and health, and its mission to serve as adviserto the nation to improve health. It works outside theframework of the US federal government to provideindependent guidance and analysis and relies on avolunteer workforce of scientists and other experts,operating under a rigorous, formal peer-review system(see http://www.IOM.edu).
How well are these strategies being taken up inthe US?In the 5 years that have elapsed since the IOM reporton adult cancer survivors, there has been increasingawareness of the growing number of cancer survivorsin the US (now numbering about 12 million, or 4% ofthe population), as well as increasing efforts at majorcancer centers to develop programs that will improvethe post-treatment management of cancer patients.However, widespread adoption of some of the key stra-tegies and recommendations has been limited, with the
exception of many of the US National Cancer Institutecomprehensive cancer centers. This is mostly becauseabout 80% of cancer care in the US occurs in commu-nity settings and not in major cancer centers. Smallgroups of oncology practitioners are the norm, and thesurgeons and radiation oncologists often do not prac-tice in the same setting with the medical oncologists.Thus, the acute treatment and post-treatment care isoften fragmented, and usually does not include thegeneral practitioner. This makes it difficult to coordi-nate post-treatment care and to ensure that the threePs are delivered when patients are in follow-up.
How about other parts of the world?I think that the needs of cancer survivors are just begin-ning to get attention in other parts of the world. TheUK, Australia, Canada and parts of the EU now havesome of these same issues on their radar and are devel-oping relevant models of care.
Figure 1 Cancer care trajectory and survivorship care. Figure adapted from the Institute of Medicine. Reprinted with permission from FromCancer Patient to Cancer Survivor: Lost in Transition, 2005, by the National Academy of Sciences, Courtesy of the National Academies Press,Washington, DC, USA.
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Are there any special cases?For childhood cancer survivors, the situation is a bitmore organized. They are fewer in number and arealmost all treated at specialized cancer centers acrossthe world. These centers often follow-up children whowere treated many years ago long into adulthood (forexample, for 30-40 years). These children often experi-ence very serious side effects from treatment (for exam-ple, short stature, endocrine deficiencies, secondcancers, premature cardiac disease) and as a result theyare more closely monitored. In the US, guidelines havebeen developed for their care (see http://www.survivor-shipguidelines.org/) by the Children’s Oncology Group(COG), and many follow-up clinics exist that are usingthese guidelines which focus on the three Ps.
Where can I find out more?Hewitt M, Greenfield S, Stovall E (Eds): From CancerPatient to Cancer Survivor: Lost in Transition. Washing-ton, DC, USA: The National Academies Press; 2006.Armstrong GT, Liu Q, Yasui Y, Neglia JP, Leisenring
W, Robison LL, Mertens AC: Late mortality among 5-year survivors of childhood cancer: a summary fromthe Childhood Cancer Survivor Study. J Clin Oncol2009, 27:2328-2338.Ganz PA, Casillas J, Hahn EE: Ensuring quality care
for cancer survivors: implementing the survivorshipcare plan. Semin Oncol Nurs 2008, 24:208-217.Ganz PA: A teachable moment for oncologists: can-
cer survivors, 10 million strong and growing! J ClinOncol 2005, 23:5458-5460.
Received: 11 January 2011 Accepted: 10 February 2011Published: 10 February 2011
doi:10.1186/1741-7015-9-14Cite this article as: Ganz: The ‘three Ps’ of cancer survivorship care. BMCMedicine 2011 9:14.
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